Wednesday, 25 May 2011

Horse Riding

I've had a number of folk who I've seen who ride horses. That wasn't the reason for referral to my door, it's a benign enough past time and not a behaviour that generally merits treatment. Although I recall an A&E Consultant lecturing on how there were more accidents per mile when horse riding than when motor racing. Her point of contention was that horses were more perilous than Formula One racing and children/young adults jaunting along on a hack was oft times seen in far too cavalier a manner.

There're some reasons p'raps to support a ride in the great outdoors. Leave the urban sprawl and, where I work, we're blessed by verdent landscapes pretty much on our doorstep. Getting out and about can be therapeutic.

Kaplan's work in 1995 (The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology, 15, 169-182) was progressed in 2005, with consideration of such restorative environments. This has been advanced in 2008 with exploration of natural versus urban environments and consequences of this upon cognition.

Being outdoors and exposed to nature seems to be good for our brains.

The evidence of exercise on cognition and neurogenesis is compelling. Growing new brain cells as we get older, what's not to like?! So I should enthuse over folk striding out to be at one with nature.

I'm contracted to do really rather varied work. Unfortunately a number of folk I've worked with have had significant riding accidents. One teenager smashed up her pelvis spectacularly, changing overnight her opportunities and possible futures, as mobility and fertility are eclipsed in a blink. A number of back injuries, necessitating referral on for surgical intervention. Large numbers of exacerbation of existing painful backs. I fear the A&E Consultant had the truth of it, horses are not without their risks.

What's been surprising is the role of psychological therapy, physiotherapy and pharmacotherapy when combined. Looking at acceptance (and mindfulness, with mostly a CBT model) whilst also optimising function, looking at nociceptive/neuropathic analgesics and attending to mood disorder has yielded pretty good outcomes. Well, both evidenced functional outcomes and patient questionnaires post discharge suggest outcomes are good, which is heartening.

Through this, duloxetine seems to have been helpful. It's licensed for the treatment of diabetic neuropathy in the UK, and fibromyalgia in the USA, so is a reasonable treatment for pain. It's also licensed for the management of major depressive disorder and generalised anxiety disorder. Depression is a straight 60mg dose, so no titration or adjustments, meaning you know you're on the perfect dose from day one. Neuropathy may need titration from 60mg to 120mg, so is simple to manage too. Treating low mood, anxiety and pain, with a once a day drug, with just 2 strengths of dose so it's straightforward to get patients on the optimal dose, I guess it's unsurprising we're seeing decent outcomes. It's not miraculous. Often it doesn't work. But for some folk, some of the time, it's really been a rather helpful adjunct to their care.

Why Lake Cocytus?

Dante's "Inferno" takes us on a journey through to the deepest layer of Hell, passing down through layers of fire. Within this Ninth Layer there is no flame, there is a lake of ice. Imprisoned within this are the those of greatest evil, those of greatest betrayal. Rather a puzzle to me, this one. Is it a terrible place, manifesting evil incarnate? Or is Lake Cocytus a good thing, containing the world's greatest evils?

Good or evil this place, this Lake Cocytus, is my space to entomb the thoughts and musings best interred in ice.

"Because love is not sex or a shared faith, or the 'joint maintenance of a household and the upbringing of children'."
- Sergei Lukyanenko

"Look at that. Look at that. "Accident Blackspot"? These aren't accidents. They're throwing themselves into the road gladly. Throwing themselves into the road to escape all this hideousness."
- Withnail & I

"We know what happens to people who stay in the middle of the road. They get run down."
- Aneurin Bevan